Successful management of severe hypoglycemia induced by total parenteral nutrition in patients with hepatocellular injury: Three cases reports

BACKGROUND Glucose imbalance is common in total parenteral nutrition(TPN).Hypoglycemia seems to be less frequent than hyperglycemia,but it influences the clinical outcome to a greater extent.Therefore,it should be effectively prevented and treated.However,there is no relevant report on how to treat hypoglycemia caused by TPN in patients with liver cell injury.CASE SUMMARY We present three patients with liver cell injury who developed severe hypo-glycemia during or after TPN infusion.The causes of severe hypoglycemia and glucose-raising strategies were discussed.According to the physiological charac-teristics of the hepatocellular injury,the ratio of nutrition components prescribed in TPN was appropriately adjusted for the three cases.We simultaneously reduced the dose of insulin and fat emulsion,and increased the dose of glucose in TPN.The blood glucose level was restored to normal range and clinical symptoms were eliminated.CONCLUSION When hypoglycemia occurs during or after TPN in patients with hepatocellular injury,physicians need to simultaneously reduce insulin and fat emulsion,and increase glucose,and correct severe hypoglycemia in time to reduce its adverse consequences.

A study of the ameliorating effects of carnitine on hepatic steatosis induced by total parenteral nutrition in rats

ＩＮＴＲＯＤＵＣＴＩＯＮＬｏｎｇｔｅｒｍｔｏｔａｌｐａｒｅｎｔｅｒａｌｎｕｔｒｉｔｉｏｎ（ＴＰＮ）ｃａｎｆｒｅｑｕｅｎｔｌｙｌｅａｄｔｏｔｈｅｄｅｖｅｌｏｐｍｅｎｔｏｆｈｅｐａｔｉｃｓｔｅａｔｏｓｉｓ．Ａｌｔｈｏｕｇｈｉｔｓｉｎｃｉｄｅｎｃｅｈａｓ...

S-adenosylmethionine in treatment of cholestasis after total parenteral nutrition: laboratory investigation and clinical application

Objective: To observe the effects of S-adenosylmethio-nine (SAMe) in the treatment of cholestasis after totalparenteral nutrition (TPN).Methods: Thirty SD rats were randomly divided intocontrol group, hypercalorie group, hypercalorie+SAMegroup, sepsis group and sepsis+SAMe group to com-pare their states of cholestasis. Sixteen patients re-ceived SAMe because of cholestasis after prolongedTPN, and the therapeutic efficacy was observed.Results: Bile flow was obviously decreased and theserum levels of total bile acid and gamma-glutamyltranspeptidase(γ-GT) were markedly increased in thehypercalorie and sepsis groups. Meanwhile, hepatocytefatty degeneration, dilatation of cholangioles, and bilesludge could be seen microscopically. SAMe adminis-tration in the hypercalorie+SAMe and sepsis+SAMegroups could increase the bile flow, decrease theserum levels of total bile acid and γ-GT, reduce thepathological damage to the liver, and clear the bilesludge in the cholangioles. Cholestasis and abnormalliver function were the main manifestations of the 16patients before SAMe administration. After SAMe treat-ment for 3 weeks, serum levels of total bilirubin, al-kaline phosphatase(AKP), γ-GT, alanine aminotrans-ferase(ALT), and aspartate aminotransferase(AST)were obviously decreased, and normalized in the 4thweek.Conclusion: SAMe could prevent and treat cholestasiswithout discontinuation of TPN.

Glutamine-supplemented total parenteral nutrition attenuates plasma interleukin-6 in surgical patients with lower disease severity

AIM: To evaluate whether the effect of Gln dipeptideenriched total parenteral nutrition (TPN) on postoperative cytokine alteration depended on the disease severity of surgical patients.METHODS: Forty-eight patients with major abdominal surgery were allocated to two groups to receive isonitrogenous (0.228 g nitrogen/kg per d) and isocaloric(30 kcal/kg per d) TPN for 6 d. Control group (Conv)using conventional TPN solution received 1.5 g amino adds/kg per day, whereas the test group received 0.972 g amino acids/kg per day and 0.417 g L-alanyl-L-glutamine(Ala-Gln)/kg per day. Blood samples were collected on d 1 and d 6 postoperatively for plasma interleukin (IL)-2,IL-6, IL-8, and interferon (IFN)-γ analysis.RESULTS: Plasma IL-2 and IFN-γ were not detectable.IL-6 concentrations were significantly lower on the 6th postoperative day in the Ala-Gln group than those in the Conv group in patients with APACHE Ⅱ≤6, whereas no difference was noted in patients with APACHE Ⅱ＞6. There was no difference in IL-8 levels between the two groups.No difference in cumulative nitrogen balance was observed on d 2-5 after the operation between the two groups(Ala-Gln -3.2±1.6 g vs Conv -6.5±2.7 g). A significant inverse correlation was noted between plasma IL-6 levels and cumulative nitrogen balance postoperatively in the Ala-Gln group, whereas no such correlation was observed in the Conv group.CONCLUSION: TPN supplemented with Gln dipeptide had no effect on plasma IL-8 levels after surgery. However,Gln supplementation had a beneficial effect on decreasing systemic IL-6 production after surgery in patients with low admission illness severity, and lower plasma IL-6 may improve nitrogen balance in patients with abdominal surgery when Gln was administered.

Analysis of Sodium and Potassium in Total Parenteral Nutrition Bags by ICP-MS and ICP-AES:Critical Influence of the Ingredients

The compounding of total parenteral nutrition solutions (TPN) in the hospital pharmacy is a high-risk activity for which a quality assurance programme is necessary. The complexity of parenteral nutrition solutions containing almost 50 ingredients makes it difficult to measure each of them. On the other hand, the assay of electrolytes such as sodium and potassium is accepted as a quality marker for estimating compounding errors. Thus, the aim of this study was to estimate the influence of ingredients on the accuracy of assays of electrolytes. Experiments were performed with aqueous working simulated solutions of sodium and potassium prepared by the addition of each nutrient step by step, (dextrose, amino acids, lipids, vitamins and trace elements). Sodium and potassium levels were measured by Inductively Coupled Plasma Mass Spectroscopy (ICP-MS) and Atomic Emission Spectroscopy (ICP-AES). The performance of these methods was compared using statistical evaluations (t-test and Mann–Whitney test).The study highlights the interference of amino acids, vitamins and trace elements when measuring sodium, but no interference was noted during the measurement of potassium. To reduce the risk and to improve the quality of compounding, we used an automated compounding device but, even in this case, the acceptance criterion for sodium and potassium determination was not <10%.

Exploring choices of early nutritional support for patients with sepsis based on changes in intestinal microecology

BACKGROUND Sepsis exacerbates intestinal microecological disorders leading to poor prognosis.Proper modalities of nutritional support can improve nutrition,immunity,and intestinal microecology.AIM To identify the optimal modality of early nutritional support for patients with sepsis from the perspective of intestinal microecology.METHODS Thirty patients with sepsis admitted to the intensive care unit of the General Hospital of Ningxia Medical University,China,between 2019 and 2021 with indications for nutritional support,were randomly assigned to one of three different modalities of nutritional support for a total of 5 d:Total enteral nutrition(TEN group),total parenteral nutrition(TPN group),and supplemental parenteral nutrition(SPN group).Blood and stool specimens were collected before and after nutritional support,and changes in gut microbiota,short-chain fatty acids(SCFAs),and immune and nutritional indicators were detected and compared among the three groups.RESULTS In comparison with before nutritional support,the three groups after nutritional support presented:(1)Differences in the gut bacteria(Enterococcus increased in the TEN group,Campylobacter decreased in the TPN group,and Dialister decreased in the SPN group;all P<0.05);(2)different trends in SCFAs(the TEN group showed improvement except for Caproic acid,the TPN group showed improvement only for acetic and propionic acid,and the SPN group showed a decreasing trend);(3)significant improvement of the nutritional and immunological indicators in the TEN and SPN groups,while only immunoglobulin G improved in the TPN group(all P<0.05);and(4)a significant correlation was found between the gut bacteria,SCFAs,and nutritional and immunological indicators(all P<0.05).CONCLUSION TEN is recommended as the preferred mode of early nutritional support in sepsis based on clinical nutritional and immunological indicators,as well as changes in intestinal microecology.

品管圈活动在降低静脉用药调配中心新生儿TPN混合调配误差率中的应用效果

目的探究品管圈活动(QCC)在降低静脉用药调配中心(PIVAS)新生儿全肠外营养液(TPN)混合调配误差率中的应用效果。方法运用QCC管理方法,确定以“降低新生儿TPN混合调配误差率”为活动主题,运用鱼骨图、柏拉图等方式分析导致新生儿TPN混合调配误差产生的真因,并据此制定整改措施,最终以有形成果和无形成果评价管理效果。结果改善后,新生儿TPN混合调配总误差率由5.30%下降至1.53%,其中抽吸量不准确误差率由1.97%下降至1.15%,排液量不准确误差率由1.43%下降至0.38%;目标达标率为131.82%,进步率为91.03%。圈员能力得到了显著提升。结论在PIVAS开展QCC管理能有效降低新生儿TPN混合调配误差率,提升新生儿的TPN混合调配准确性以及用药安全性。

Endoscopist's approach to nutrition in the patient with pancreatitis

Nutritional therapy has an important role in the management of patient with severe acute pancreatitis.This article reviews the endoscopist's approach to manage nutrition in such cases.Enteral feeding has been clearly validated as the preferred route of feeding,and should be started early on admission.Parenteral nutrition should be reserved for patients with contraindications to enteral feeding such as small bowel obstruction.Moreover,nasogastric feeding is safe and as effective as nasojejunal feeding.If a prolonged course of enteral feeding(>30d) is required,endoscopic placement of feeding gastrostomy or jejunostomy tubes should be considered.

Impact of fish oil enriched total parenteral nutrition on elderly patients after colorectal cancer surgery

Background Polyunsaturated omega-3 fatty acids may beneficially influence healing processes and patient outcomes.The aim of this research was to study the clinical efficacy of fish oil enriched total parenteral nutrition in elderly patients after colorectal cancer surgery.Methods Fifty-seven elderly patients with colorectal cancer were enrolled in this prospective,randomized,double-blind,controlled clinical trial.All patients received isocaloric and isonitrogenous total parenteral nutrition by continuous infusion （20-24 hours per day） for seven days after surgery.The control group （n=28） received 1.2 g/kg soybean oil per day,whereas the treatment group （n=29） received 0.2 g/kg fish oil and 1.0 g/kg soybean oil per day.Blood samples were taken pre-operatively,and at days one and eight after the operation.The plasma levels of CD4,CD8,CD4/CD8,interleukin 6 （IL-6） and tumor necrosis factor a （TNF-a） were measured.Clinical outcomes were then analysed.Results Patient characteristics were comparable between the two groups.At day eight post-surgery,IL-6,TNF-α and CD8 titres were lower in the treatment group when compared to the control group; these results reached statistical significance.In the treatment group,there were fewer infectious complications and incidences of systemic inflammatory response syndrome （SIRS）,and shorter lengths of hospital stay were observed.The total cost of medical care was comparable for the two groups.No serious adverse events occurred in either group.Conclusions Fish oil 0.2 g/kg per day administrated to elderly patients after colorectal surgery was safe and may shorten the length of hospital stay and improve clinical outcomes.

Effects of total parenteral nutrition on drug metabolism gene expression in mice

Parenteral nutrition-associated liver disease(PNALD)is a liver dysfunction caused by various risk factors presented in patients receiving total parenteral nutrition(TPN).Omega-6 rich Intralipid?and omega-3 rich Omegaven?are two intravenous lipid emulsions used in TPN.TPN could affect the hepatic expression of genes in anti-oxidative stress,but it’s unknown whether TPN affects genes in drug metabolism.In this study,either Intralipid?-or Omegaven?-based TPN was administered to mice and the expression of a cohort of genes involved in anti-oxidative stress or drug metabolism was analyzed,glutathione(GSH)levels were measured,and protein levels for two key drug metabolism geneswere determined.Overall,the expression of most genes was downregulated by Intralipid?-based TPN(Gstpl,Gstml,3,6,Nqol,Ho-1,Mt-1,Gclc,Gclm,Cyp2d9,2f2,2b 10,and 3a11).Omegaven?showed similar results as Intralipid?except for preserving the expression of Gstml and Cyp3a11,and increasing Ho-1.Total GSH levels were decreased by Intralipid?,but increased by Omegaven?.CYP3A11 protein levels were increased by Omegaven?.In conclusion,TPN reduced the expression of many genes involved in anti-oxidative stress and drug metabolism in mice.However,Omegaven?preserved expression of Cyp3a11,suggesting another beneficial effect of Omegaven?in protecting liver functions.

Glycemic Variation in Tumor Patients with Total Parenteral Nutrition

Background：Hyperglycemia is associated with poor clinical outcomes and mortality in several patients.However,studies evaluating hyperglycemia variation in tumor patients receiving total parenteral nutrition （TPN） are scarce.The aim of this study was to assess the relationship between glycemia and tumor kinds with TPN by monitoring glycemic variation in tumor patients.Methods：This retrospective clinical trial selected 312 patients with various cancer types,whose unique nutrition treatment was TPN during the monitoring period.All patients had blood glucose （BG） values assessed at least six times daily during the TPN infusion.The glycemic variation before and after TPN was set as the indicator to evaluate the factors influencing BG.Results：The clinical trial lasted 7.5 ± 3.0 days adjusted for age,gender,family cancer history and blood types.There were six cancer types：Hepatic carcinoma （HC,21.8%）,rectal carcinoma （17.3%）,colon carcinoma （CC,14.7%）,gastric carcinoma （29.8%）,pancreatic carcinoma （11.5%）,and duodenal carcinoma （DC,4.8%）.The patients were divided into diabetes and nondiabetes groups.No statistical differences in TPN glucose content between diabetes and nondiabetes groups were found;however,the tumor types affected by BG values were obvious.With increasing BG values,DC,HC and CC were more represented than other tumor types in this sequence in diabetic individuals,as well as in the nondiabetic group.BG was inclined to be more easily influenced in the nondiabetes group.Other factors did not impact BG values,includiug gender,body mass index,and TPN infusion duration time.Conclusions：When tumor patients are treated with TPN,BG levels should be monitored according to different types of tumors,besides differentiating diabetes or nondiabetes patients.Special BG control is needed for DC,HC and CC in both diabetic and nondiabetic patients.If BG overtly increases,positive measurements are needed to control BG values.The ClinicalTrials.gov ID is NCT02024321.

添加短链脂肪酸的TPN对术后化疗大鼠结肠粘膜细胞增殖作用的研究

目的探讨添加短链脂肪酸(SCFAs)的全肠外营养(TPN)对术后化疗大鼠结肠粘膜细胞增殖作用的影响。方法30只SD大鼠在无渣饮食2d后建立TPN和结肠吻合模型。术后随机分为TPN对照组(对照组)、化疗+TPN组(化疗组)、化疗+TPN+SCFAs组(SCFAs组),每组10只。进行实验5 d,术后第6 d留取标本采用流式细胞术分析结肠粘膜细胞周期,观察其增殖情况。结果化疗组结肠粘膜细胞增殖期百分比(6.23±2.75)%显著低于对照组[(9.81±2.78)%,P=0.014]和SCFAs组[(11.57±3.54)%,P=0.001];化疗组结肠粘膜细胞的增殖指数(11.87±2.61)%显著低于其他2组[(20.25±7.22)%,P=0.002;(19.70±5.12)%,P=0.003]。结论添加SCFAs的TPN能促进术后化疗大鼠结肠粘膜细胞的增殖。

Characteristics and outcomes of avoidant/restrictive food intake disorder in Japanese elementary-school students on total parenteral nutrition

The clinical outcomes of adolescents with avoidant/restrictive food intake disorder(ARFID)remain unclear.Furthermore,no report has compared the characteristics of ARFID and restricting-type anorexia nervosa(R-AN)in elementary-school students on total parenteral nutrition(TPN).This study retrospectively reviewed inpatients diagnosed with ARFID or R-AN between 2005 and 2019.Patients with ARFID(two boys and seven girls)and R-AN(13 girls)were hospitalized because of rapid physical deterioration,and nutrition therapy was continued without withdrawal.The ARFID group exhibited significantly lower body weights at admission than the R-AN group and gained an average of 6.5 kg during hospitalization;furthermore,the monthly weight gain during hospitalization was significantly higher,and no relapse was observed.Early physical improvement in ARFID resulted in good recovery.In conclusion,TPN can be easily introduced to patients with ARFID,in whom aversive eating is a concern,and is a suitable treatment for ARFID.

TPN,丙氨酰-谷氨酰胺双肽在重症急性胰腺炎非手术治疗中的意义

目的 观察全胃肠外营养、全胃肠外营养 +丙氨酰 -谷氨酰胺双肽在急性重症胰腺炎非手术治疗中的作用 .方法 6 4例急性重症胰腺炎依据不同治疗方案随机分为 3组 . I组采用传统保守治疗方案 ,将 II组在传统保守治疗原则基础上实施全胃肠外营养 (TPN)治疗 ,III组在 II组方案基础上给予丙氨酰 -谷氨酰胺双肽治疗 ,观察各组血清白蛋白水平、血淀粉酶恢复正常时间、并发症发生率、死亡率、患者住院日数、体质量并加以比较 .结果 3组患者入院时血清白蛋白分别为 (2 8.7± 4 .92 ) g· L- 1 (I组 )、(2 9.1± 4 .84 ) g· L- 1 (II组 )和 (2 9.3± 4 .5 0 ) g· L- 1 (III组 ) ,治疗 2 wk后 I组、II组和 III组血清白蛋白分别为 (30 .1± 4 .5 3) ,(35 .7± 4 .6 2 )和 (36 .8± 4 .5 7) g· L- 1 ,3组死亡率分别为 34.8% (8/ 2 3) ,14 .3%(3/ 2 1)和 0 % ,并发症发生率分别为 91.3% (2 1例次 / 2 3)、4 7.6 % (10例次 / 2 1)、2 0 .0 % (4例次 / 2 0 ) ,其中 III组未出现胰腺周围感染 .患者体质量变化 I组与 II,III组相比差异显著 .结论 在急性重症胰腺炎传统的非手术治疗方案基础上 ,给予 TPN或 Ala- Gln强化 TPN治疗 ,可明显改善患者的营养状态 ,减少死亡率及并发症的发生率 .同时 ,Ala- Gln强化

短链脂肪酸对TPN大鼠小肠粘膜结构及细胞增殖作用的研究

目的：探讨短链脂肪酸（ＳＣＦＡｓ）对ＴＰＮ大鼠小肠粘膜的保护作用。方法：将３０只近交系Ｗｉｓｔｅｒ（ＲＴ１Ｋ）大鼠随机分为假手术对照组、常规ＴＰＮ组及ＳＣＦＡｓ－ＴＰＮ组，进行为期１４天实验，结束后观察小肠粘膜的形态学变化和细胞增殖情况。结果：常规ＴＰＮ组大鼠肠粘膜绒毛高度、宽度及隐窝深度较正常对照组均有显著减少，其增殖指数也显著降低；ＳＣＦＡｓ－ＴＰＮ组上述指标明显升高，与对照组基本接近。结论：短链脂肪酸（ＳＣＦＡｓ）能促进ＴＰＮ大鼠小肠粘膜细胞增殖，维持其正常形态，从而有保护肠粘膜机械屏障的作用。

静脉用药集中调配中心TPN审方模块软件的研发

目的:研发监测全胃肠外营养(total parenteral nutrition,TPN)、评价影响全胃肠外营养用药安全因素的合理用药审方软件,协助责任药师开展全胃肠外营养合理用药审查工作。方法:随机抽取我院外科药房2010年1-9月已开展静脉用药调配科室的住院病人TPN医嘱记录,针对大量使用电解质对TPN稳定性的影响、液体补给、热量供给、热氮比、糖脂比、配伍禁忌等问题,在Wins/XP平台,中文操作系统环境下,基于医院信息系统(HIS),以Delphi程序编辑工具和SQL favor 2005数据库系统开发医院TPN审方系统模块。结果:我院药品保障中心根据TPN合理用药审查要求,自主开发了全胃肠外营养审方系统模块软件,主要包括TPN监测效果评价、单病人TPN的详细医嘱信息、单病人TPN审方指标明细、TPN基本营养配比结构图、TPN审方指标的雷达图5大部分。可实时监测TPN临床用药状况,详实记录和评价TPN的合理性,同时对不合理TPN医嘱的原因和相关因素进行关联性评价,为提高医院TPN用药安全提供客观的数据支持。结论:该软件操作简便、信息记载全面、评价指标明确、图表分析形象化,为药师TPN审方提供了强有力的信息化数据支持。

谷氨酰胺促进TPN大鼠小肠代偿的分子机制研究

将２０只短肠ＳＤ大鼠随机分成单纯ＴＰＮ组及ＧＩｎ－ＦＰＮ组，行肠粘膜上皮细胞增殖。凋亡及相关基因表达的检测，探讨谷氨酰胺（glutamine,Gln）促进ＴＰＮ短肠大鼠小肠代偿的分子机制．结果表明：单纯ＴＰＮ可造成大鼠小肠粘膜明显萎缩，添加Ｇｌｎ的ＴＰＮ可显著缓解肠粘膜萎缩．其肠粘膜上皮细胞ＰＣＮＡ表达显著增高，凋亡指数下降．Ｇｌｎ抑制细胞凋亡的作用与ｂｃｌ－２表达上调及ｂａｘ表达下调密切相关．

TPN联合生长激素对胃肠道恶性肿瘤患者术后应激反应的抑制作用

目的探讨胃肠道恶性肿瘤患者术后完全胃肠外营养(TPN)基础上给予生长激素(GH)促进机体合成代谢的机理。方法将94例胃肠道恶性肿瘤手术患者按随机数字表法随机均分为TPN组和TPN+GH组,术后第1、3及7d分别测定其TNFα、IL1、IL6及C反应蛋白(CRP)值。结果TPN+GH组的TNFα、IL1、IL6及CRP值在术后第1、3及7d均低于TPN组相应时相。结论外源性GH可抑制胃肠道恶性肿瘤患者术后TNFα、IL1、IL6及CRP的产生,进而阻断炎症因子诱导的GH不敏感反应所致的高分解代谢为特征的合成代谢障碍,促进机体合成代谢。

TPN联合重组人生长激素在腹部大手术的应用

目的：研究腹部大手术后联合使用重组人生长激素（ｒｈＧＨ）和ＴＰＮ对病人氮平衡及营养状况的影响。方法：选择２７例接受腹部大手术和完全胃肠外营养的病人，随机分为研究组（１５例）和对照组（１２例），术后连续７天，每天皮下注射重组人生长激素４单位或安慰剂（等渗盐水）。结果：ｒｈＧＨ＋ＴＰＮ显著促进了氮平衡的恢复，提高了血浆白蛋白和转铁蛋白水平，增加了体重和肌酐／身高指数，并降低了血尿素氮，但对肱三头肌皮皱厚度的改变无统计学意义。结论：术后应用重组人生长激素能提高ＴＰＮ支持的疗效。

表皮生长因子增强TPN减少放射性肠炎细菌易位及其机理的实验研究

腹部受辐射 ( abdominal rdiation,AR)致放射性肠炎常导致肠粘膜屏障损害和细菌易位。接受长期 TPN( total parenteral nutrition,TPN)改善营养的同时 ,可加重细菌易位 ,并导致多器官功能衰竭等致死性并发症。即使给予肠粘膜代谢所需的谷氨酰胺 ( Glutamine,Gln)亦不能完全防治其损伤。EGF( epidermal growth factor)是胃肠道粘膜上皮生长和增殖的介质。本研究在 SD大鼠放射性肠炎模型上观察了 EGF增强 TPN对放射性肠炎细菌易位及对损伤的肠粘膜修复的影响 ,结果发现 ,经 EGF增强的 TPN治疗大鼠放射性肠炎 ,大鼠死亡率、细菌易位率均较不用 TPN及应用不含 EGF的 TPN组明显下降 ,体重、粘膜 /肠段重量比、绒毛高度、面积、小肠 Gln摄取率及 DNA含量均明显升高。机理为 :EGF对小肠粘膜有明显的滋养作用。EGF增强 TPN在提供较完善营养及肠道充分休息 ,促进创伤愈合的同时 ,通过提高肠粘膜对 Gln的摄取能力 ,维持肠粘膜上皮的正常代谢 ,加速修复损伤的肠粘膜屏障 ,降低细菌易位率 。